PALLIATIVE CARES

Nursing is an important part in palliative cares and in the death process because we stay much time with the patients and the family and we have to know how communicate with them, how answer their questions… So is important that we distinguish different methods to do this.

Basic principles

• Velocity of communication according to the assimilation of each person.
• The diagnostic, treatment and prognosis must be in different sessions, never in the same because the patient has to assimilate the information.
• If the patient won’t know the information we have to respect his posture and say her/his that if he/she change the opinion they can talk with us.
• Never take off the hope but neither generates it.

Bad notices

It’s an information that alters the vision of the patient about her/his future. Here are some directives to follow when you are going to say bad notices:

In this article The patient’s right to information: the art of communicating,there are 2 investigations about if the patients would know their diagnosis. Both studies mark that that if the patients know the diagnosis, the prognosis, the treatment… is better for their. I’m agree with this conclusion because if you know what happen with your body, what is wrong… you accept better the treatment and the cares.

Also, it’s described the silence pact. It’s an interesting point because in one study, 70% of the families occult the information to the sick. This situation is worse for the patient and in this article shows how we can confront this.
In this other guide there are 6 directives called Communication strategies of Buckman.

Loss

  - Death of a loved person.

  - Loss of an organ or corporal function.

  - Disaster.

  - Family separation.

  - Retirement.

  - Loss of employment.

Mourning

Emotional adaptation process that follows any loss and its associated physical and emotional symptoms.

Mourning stages

  1. Negation.

  2. Anger.

  3. Negotiation.

  4. Depression.

  5. Acceptance.

In this video are showing the stages.

Palliative cares

With this cares we pretend to get better the quality of life of the patient and their family by early diagnosis, adequate evaluation and a good treatment of the pain and other physical and spiritual problems.

Palliative medicine

 - That’s initiate when the patient doesn’t answer to the curative therapy.

 - Finish with the maximum comfort to the patient.

 - Duration: 60 – 65 days.

Diseases that need the palliative cares:

  • Cancer in terminal stage.

  • HIV and AIDS.

  • Organic insufficiency.

  • Neurodegenerative diseases.

Pain evaluation

With this scale we evaluate the pain.

Analgesia scale by WHO.

NURSING CARES

Anorexia

• Less food in big plates.
• Adequate preparation of the food.
• Delicious food for the patient.

Vomits and nauseas
  - Adequate diet and drugs.

Constipation
  - Increase the intake of liquids.
  - Restriction of diets rich in fiber.
  - Drugs.

Mouth
  - Clean lips and oral mucous.
  - Eliminate place and rests.
  - Prevent oral infection.
  - Eliminate pain in oral intake.

Finally, in this video, patients, family of patients and sanitary staff of an ospital have explained how they live the palliative cares, what can we do and how we can confront the death.

DIGESTIVE PATHOLOGIES

CONSTIPATION

Evacuation of dry, limited and infrequent feces (less than 2 depositions per week). Causes of the constipation:

  - Obstructive, cancer, hernias…

  - Diet poor in fiber, anal fissure, hemorrhoids, irritable colon.

  - Laxative, antidepressant, antacid, opiate.

  - Diabetes, uremia, hypothyroidism.

  - Trauma, Parkinson, dementia, depression.

Complications:

“Fecaloma”: fecal impaction in rectum or colon. The patients have colic pains and diarrheas. To remove the fecal impact we have to do the next instructions:

  1. Relax the patient and say his/her to breathe deeply.

  2. Introduce the finger in the rectum 5 – 10 cm with a lubricant.

Anal fissure: as a consequence the effort to defecate, has been produced a passive congestion of the mucosa near the anus.

FECAL RETENTION

There are 3 fields we can actuate:

- Consume vegetable fiber 10 – 60 g/day and more liquids. The consume of fiber increase the fecal mass, as consequence the peristalsis.

- Educate to the patient to evacuate regularity every day. Sit down in the toilet between 10 and 15 minutes after the breakfast.

- The physical exercise promotes the abdominal press.

Food that contains fibre:

The photo on right is about food rich in fibre. Its preferable intake insoluble fibre.

Javier Martínez Peromingo, María Rodríguez Couso , M.ª Paz Jiménez Jiménez, Guillermo Yela Martínez. Tratado de Geriatría para residentes. Estreñimiento e incontinencia fecal

BLOW OUT

Surgical creation of a temporal or permanent orifice that join the digestive tube with the exterior in abdominal wall.

Nutritional recommendations to patients with blows out. 

FECAL INCONTINENCE

Is one of the principal geriatrics syndromes that affects in quality of life and overloading to the principal career.  The impact isn’t only physical, also economic and psychosocial.

Types of fecal incontinence:

Minor:

• Soiling (get dirty the underwear): hemorrhoids, diarrhea, immobility, dementia and depression.
• Gas incontinence: avoid flatulent food and carbonic drinks.
• Urgency to defecate: they feel the feces in the rectum but they aren’t able to maintain the incontinence until go to the toilet.

Greater:

• Lesion in the pelvic floor.
• Drugs: laxatives and antibiotics.
• Rectum cancer.
• Neurologic alterations: central, spinal cord, and peripheral.

Risk factors:

  - Urinary incontinence.

  - Immobility.

  - Previous neurologic diseases.

  - Cognitive alteration.

  - More than 70 years.

Parks classification

Rank 1: normal continence.

Rank 2: difficulty to the control of gases and liquids.

Rank 3: total incontinence to liquids.

Rank 4: incontinence to solids feces.

Nursing cares

• Programmed the defecation, increase the hydric ingest and fiber, physical exercise…
• Avoid the soap, toilet paper, rag and towels, realize a soft washing with tepid temperature…
• Treatment the fecal impaction.
• Accessible toilet.
• Using of absorbents.

DYSPHAGIA

The dysphagia is the difficulty to swallow the liquids or solids elements because one or more stages of swallowing are affected. Video.

Causes

Treatment

• Present the food in little quantity.    
• Not mix solids with liquids consistency.
• Avoid the contact the spoon with the teeth.
• Relax ambient, not force.
• Flavor the food with nutrients, proteins…

INSTABILITY AND FALLS

The falls are an important cause of wounds, incapacity and death in old people. These people have more problems to maintain the stability that is manifested by careful march (rigid posture, short and slow steps, instability),

Alarm indicator

 - Ocular: decrease of visual acumen, near and nocturne vision.

  - Hearing: excessive earwax, increase of threshold tone.

  - Nervous system: alteration of the reflexes, decrease of reaction time…

Consume of sedative is the most important element in the risk of falls how we can see in this article Epidemiología de caídas de ancianos en España. Una revisión sistemática, 2007 and in this other Factores de riesgo de accidentes en la edad geriátrica.

Other risk is negation to physical limitations, so the patient doesn't know about their her/his own limitation and she/he do all without some type of care causing much falls and other accidents.

The nurse must insist in this point, treat to convince her/his about the limitations y how to confront the problems that it cause.

Risk factors

  - More than 75 ages.

  - Alteration of stability and march.

  - Previous falls.

  - More than 4 drugs.

  - Fragile old people.

  - Muscle debility.

  - Decrease of vision.

Physical consequences

Fracture, hematoma, burns, pain injuries in delicate tissues.

Psychosocial consequences

Aggressiveness, behavior upset, loss of self-esteem and increase of social isolation.

After fall syndrome

The patient has to adopt measures to prevent other fall. The primary prevention includes:

  - Life habits: maintain functional capacity, exercise and not toxics habits.

  - Environmental security measures: in home and in community environment.

One form to count the risk fall in old people is with the Downton scale. 

The measures to prevent the falls:

  - Avoid slippery ground, irregular or wet.

  - Good illumination in all the rooms.

  - Rooms without obstacles and have to be organized.

  - Handrails in beds.

  - Use of canes.

What to do in a fall

• Evaluate the state of the patient and some possible injuries.
• Inform to the doctor or to the urgency service.
• Don’t move the patient if we suppose there would be a fracture.
• Observation.

Video. In this video is explained the risk factors and what to do when a patient suffer a fall.

Third prevention

The purpose of this prevention is reduce the consequences of falls to avoid the after – fall syndrome.

• Teach to the patient to stand up to avoid the dehydration, hypothermia, pneumonia…
• Rehabilitate the stability with an exercise program.
• Educate the march: help with canes.
• Therapy to support.

As in many geriatric syndromes, the best actuation we can do is the prevention. Normally we go to patient’s homes when we have to realize some cure, put an injection… but in my opinion we should visit their houses to observe the risks they can have. With this, we’ll advise to patient and family how they can fix this.

NEUROLOGIC DISEASES

Minor cognitive alteration: intellectual decrease of clinical appearance but there isn’t functional incapacity. If would be this last, it will denominate dementia.

Petersen’s Rules to include minor cognitive alteration:

• Memory fails.
• Normal general cognitive efficiency.
• Absence of functional defects in day – to – day activities.

DETERIORATION COGNITIVE EVALUATION

  
• Memory: it loss the work memory, episodic and free memory.
• Language: it loss the denomination and decreased the verbal fluency.
• Decreased the reasoning, capacity to resolve problems and the velocity to process the information.
• It preserves the attention.
• Neurologic evaluation: level of attention, orientation, collaboration, senses, muscle tone, trembling or other moves.

It’s important to identify the:

• Delirium: alterations in the attention and the level of conscience.
• Depression: loss of memory, psychomotor slowing – down, less motivation to do the tests.

Scale’s evaluation:

• Mini mental state examination de Folstein (MMSE): examine the orientation, attention, calculation, memory, language and constructive ability.
• Memory impairment screen (MIS): explore de memory.
• 7 minutes test: explore the aspects has been altered in the Alzheimer.

DEMENTIA

Decrease of memory and psychological alterations. 

Primary degenerative dementia

  - Alzheimer, Pick disease, Parkinson disease, Huntington…

Vascular dementia

  - Because of ischemic, heart attack, hemorrhage…

Secondary dementia

  - Metabolic, endocrine, infection, drugs, psychiatric…

ALZHEIMER

Deterioration of memory, destruction of intellectual function and change of personality. It is classifies in 3 states:

First state:

• Memory: loss of memory, difficulty to remember nouns or words, loss in family ways…
• Language: decrease of communication, reduction in vocabulary, without facial expression, to say impertinences…
• Behavior and mood: change of mood, depression, facility to distraction, necessity to look for people or places families…
• Coordination: slowing – down of reaction time, incapacity to drive.

Second state:

• Memory: unknowing about all the recent events.
• Language: repeat the same words and phrases, to speak slowly, decrease demonstration of affection, shaking, hallucination, dream alteration.
• Coordination: loss of coordination and equilibrium, difficulty to walk and write.
• Own care: necessity of help to wash, choose the cloth, fecal and urinary incontinence.

Final state:

• Memory and language: incapacity to learn new concepts, loss of memory of recent and past events, reduction of vocabulary, incapacity to read and comprehension and repeat words or phrases.
• Behavior and mood: frequently shaking, incapacity to remember the career, difficulty to walk, write, sit down, smile or swallow.
• Own care: necessity to most help to realize the daily activities life.

Treatment

First state: antidepressant, stimulants or other drugs, do exercises in group or individually like puzzle, read... or physical activities.

Final state: morphine and counsel.

Global deterioration scale de Reisberg

This scale evaluates the patients with Alzheimer and classifies them in 7 states.

Communication and organization in home

Communication

  - Verbal: short and less words and simple phrases.

  - Nonverbal: gesture, smile, silence, corporal posture, facial expression.

Organization:

Sign the rooms with draws or simple words and remodel the rooms if is necessary.

Video about the Alzheimer, his symptoms, how to communicate with the patient…

DELIRIUM

It’s a syndrome with alteration in the level of conscience, attention, memory, orientation, thought, language or perception. The patients also have illusion and hallucination because he/she misunderstand the reality.

Risk factors:

•  Serious disease, depression, alcohol, dehydration, malnutrition.
•     Iatrogenic, physical restriction, use of urinary catheter.

Non pharmacology treatment

-         The patient has to have a mater, help in the orientation, lit room…

Pharmacology treatment

-         Haloperidol, tioridacina, levopromacina…

Video. How to recognize the delirium.

IMMOBILITY

Decrease of the capacity to do the daily activities because of the motor function deterioration.

Causes of the immobility

Physiological:

  - Decrease of mass and strength muscular, senile march.

  - Decrease of sensibility and reflex.

  - Decrease of cardiac frequency, aerobic capacity.

  - Decrease of elasticity of thoracic wall.

Usual diseases:

  - Osteoarthritis, arthritis, osteoporosis, fractures…

  - Brain damage, Parkinson, dementias…

  - Cardiac insufficiency…

  - Visual deficits, vertigo.

  - Depression.

Environmental causes:

  - Obstacles.

Nursing evaluation

Anamnesis:

  - Determine the type and frequency that the patient realize exercise like footing, ride a bike…

  - How start de immobility and the rank.

  - Pharmacology history.

  - Risk factors.

  - Analyze social factors.

General exploration

We must explore all the systems like cardiorespiratory, musculoskeletal, neurologic, skin, sensorial…

Mental evaluation

  - Memory, attention, concentration… We’ll use Mini-examen cognitive. 

  - Detect anxiety or depression. For this we’ll use Geriatric Depression Scale. 

LEVEL MOBILITY EXPLORATION

To do that, the patient have to wear his usual clothe and help mechanisms (cane). It will be examined the mobility in the bed, in the chair, in the bathroom… all the rooms in the house.

Next, we’ll test de march and equilibrium with scales and tests.

• Timed Up and Go test: the patient has to stand up and sit down in a chair. This test predicts the capacity to move independent. 
• Tinetti scale: evaluate the march and the equilibrium. 

Actuation plane

  - Treatment the cause of the immobility.

  - Plane rehabilitation.

  - Use of helps and adaptations to patient’s house.

General cares

  - Postural changes.

  - Hygiene.

  - Massage.

  - Padded.

  - Liquids and food contribution.

Prevention of complications

• Control de cardiac frequency, blood pressure…
• Tell to patient that he must cough and expectorate, use clapping…
• Inspect the mouth, teeth. Promote to have lunch with someone, to not be alone.
• Maintain a correct position during the urination. Exercise the abdominal wall.
• Promote the expression of the feelings and emotions. 

IMMOBILITY PATIENT IN BED

The changes would be realized every 2 hours. If it’s possible, the patient must do exercises in the bed.

SEATED IN THE ARMCHAIR 

In the armchair, the patient has to stay straight with pillows. The legs must to be elevated over a footstool to prevent the edema.

WALK

The patient must walk every day, slowly and increasing the distances. He/she can use a cane or not.


It’s important motivate and promote the exercise in the ageing because the immobility together with the natural process of ageing result in serious problems like depression, ulcers, loss of muscle mass…

We must show them different ways to do exercise, if its possible with other old people. This helps will tell to the family to, to guarantee us that our patients do something to combat with the immobility and her consequences.

PRESSURE ULCERS

This type of wounds is a damage in the skin and other tissue around of the skin that is caused by pressure in much time.

These njuries is produced in old man with immobility and more than 70% appear in old man with more than 70 years.

It’s important to know that 95% of PU is avoided, and the best actuation we can do is the prevention in risk factors.

The areas more damaged are bone protuberance, like sacrum and upper part of the femur.

RISK FACTORS

Pathological:

  - Skin damages.

  - Oxygen transport upset.

  - Nutritional deficits: overweight, anemia, thinness.

  - Cancer, infection.

  - Coma, confusion or drugs.

  - Fracture, brain damage.

  - Sensorial deficit.

  - Urinary and fecal upset.

Treatment:

  - Immobility.

  - Chemotherapy and radiotherapy.

Situational:

  - Hygiene absence.

  - Wrinkle in the clothes.

  - Immobility caused by pain or fatigue.

By the environmental:

  - Absence of sanitary education.

  - Absence of rules in the planning to the treatment.

  - Overloading of work.

CLINIC EVALUATION

To evaluate the pressure ulcer risk we use two scales: Braden and Norton.
Braden Scale has a specify of 64 – 77%.

Norton Scale has a specify of 61 – 94%.

Localization of the wound
In the consult, we must do a global valuation, and localize and count the ulcers. We evaluate the next notes:
  - Ulcer’s precedent.
  - Personal, family and pharmacology precedents.
  - Physical exploration.
  - Treatment plain.

Define the state of the ulcer
We use the classification of Byrne and Feld that contain 4 states (this classification doesn’t include the necrotic tissue.

Before to evaluate the state, we have to move away the necrotic tissue.
  - State 1: erythema doesn’t disappear and the epidermis is intact.
  - State 2: ulcer like an abrasion or crater less deep.
  - State 3: injury or necrosis of the subcutaneous tissue.
  - State 4: affected to the muscle and maybe the bone.

State 1

State 2

State 4

State 3

Area and volume of the ulcer
Include information about the area and the volume. This last is realized by the Wolter and Cols. Technique.

This technique consist in introduce serum in the ulcer and count how much serum there is in the wound.

TREATMENT
In this video is explained the ulcers, their states and all the treatment.

Cleanliness:
We use serum with a syringe in the wound directly. We only use antiseptic when:
  - Wound with lifeless tissue that is going to be debridement.
  - Ulcers with infection by Acinobacter

Debridement:

• Surgical: move away lifeless tissue with a surgical technique. Its needed expert professional and asepsis. Video
• Enzymatic: in dry ulcers we use “colagenasa, estreptoquinasa y fibrolisina” before the debridement. Video
• “Autolítico”: is a wet heal to promote the immune system to destroy the necrotic tissue. Video

DRESSING
“Hidrogeles”: 
  • Ulcers with necrotic tissue. 
  • It has to cover with other dressing. 
  • Promote the debridement.

“Hidrocoloides”:
  • Treatment to vascular and pressure ulcers with less exude.
  • Protect the wounds.
  • This dressing can wet it.
  • When the dressing contact with the exude, it forms a gel that alleviate the pain.
  • Not use in case of infection.
  • Move away in 3 or 4 days.

“Alginatos”:

• Highly absorbent.

• Vascular and pressure ulcers, burns and exudative and infect injury.
• It has to cover with other dressing.

Foam:
  • Highly exude.
  • Compressive therapy.

“Hidrocapilares”:
  • Levels exude highly.
  • It absorbs great exude.

Antimicrobial dressing of silver:
  • In infect ulcers.

Foam

Hidrogel

Hidrocapilar

                                                  











VASCULAR NURSE EXPLORATION
  - Color and temperature of the skin: cold, pallid, red, cyanotic.
  - Atrophy cutaneous, necrosis, gangrene, arterial ulcers…
  - Ploy exploration: Allen test (video, upper extremities) and Samuels’s arch ischemic (lower extremities).

Ankle and arm rate
  - Define the arterial ulcer and classify it. Video

With this chart you can calculate the result.

Depend of the result:

  - 0,9 – 1,3: repeat it between 2 or 3 years.

  - > 1,3: control de risk factors. Periodic revisions, care of the feet.

  - 0,5 – 0,89: exercise, drugs, care of the feet.

  - < 0,5: move on vascular surgery.

When I was in my first practice, in surgery floor and in medical center, the ulcers were treated correctly, because they use the dressing according to the exude, infection, state… But I never saw if the nurses measured the ulcers.

DIABETIC FOOT
Include the diseases causes by ischemic, neuropathy or infection. These can cause the apparition of ulcers because of a traumatism.

Wagner classification:

Risk factors
  - Neuropathy.
  - Infection.
  - Tobacco and alcohol.
  - Feet alterations.

Education to the patient

• Inspect the feet, their colors, wounds, blister or some graze.
• Prevent the injuries: always wearing some type of shoes, never barefoot; avoid burns, use adequate utensils to the hygiene of skin and nails.
• Wash with tepid water, soap with neutral pH, meticulous drying and moisturize the skin.
• To cut the nails: after de shower, straight.
• Wounds:  wash the wound, dry it and use antiseptic.

NUTRITION
According to some articles, like Revisión sistemática del soporte nutricional en las úlceras por presión or Valoración del riesgo de úlceras por presión en una Unidad de geriatría, the nutrition is very important such as in prevention as in treatment of ulcers.

The patients who are more nourished, the healing of their ulcers are faster than the patients who are undernourished.

I think this point is very important because when the patients are hospitalized is our labor to give their correct nutrition and evaluate their nutritional state.

Finally this subject is too important because in Spain the population is very old and there are a lot of old people who require special cares comparing with young people.